Note: If this Medicare Authorization form doesn’t apply, you may stop at this point, otherwise, please continue.
Submitting this form authorizes us to release information and receive payment from Medicare.
This Authorization Remains in Effect Unless Revoked by me in Writing:
- I hereby authorizePremier Ophthalmology, LLC hereinafter referred to as “Provider”, to provide information concerning any treatment rendered to me to: a) my insurance carrier(s); b) my primary care physician c) any medical practitioner “Provider” may refer me to for further medical or therapy treatment.
- I authorize as necessary to process insurance claims or required for utilization review or quality assurance activities, the release of any medical information,including confidential information related to psychiatric care, drug, and alcohol abuse, and HIV / AIDS treatments.
- I hereby assign to“Provider” all applicable payments to be received from my insurance carrier(s) for medical services rendered. I understand that any remaining credit balance shall be refunded directly to me.
- I hereby agree thatI am personally responsible for ensuring that all charges for services rendered are paid by either myself or my insurance carrier(s)
I further authorize “Provider” to utilize any modern form of transferring this documentation – including, but not limited to, the US Mail, Federal Express, telefacsimile (faxes), couriers or other similar methods – to its requested destination.
I authorize any holder of medical information to release to the Health Care Financing Administration, i.e., Medicare, and its agents, any information needed to determine those benefits or the benefits payable for related services.